Worker Rights Complaint Form (F700 148 000) F700 000
User Manual: F700
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Worker Rights Complaint Form Instructions What types of worker rights complaints can L&I accept? L&I accepts complaints on the Worker Rights Complaint Form for. . . In Section C of the form: In Section D of the form: Unpaid minimum wages, overtime, final pay, or • • Meal or rest periods not given. hours worked. Payroll deductions you did not agree to, not • • Violations of child labor laws. including deductions for required taxes. Unpaid tips, gratuities, service charges. • • RN or LPN overtime law not followed. Paid sick leave. • • Employer retaliated against me. IMPORTANT: If we find that your employer owes you money, we cannot guarantee that we will be able to collect it for you. Also, you have three years from the payday your wages were due to file your complaint. Please keep this in mind when you decide to file your complaint with us. On separate complaint forms, L&I also accepts for the following complaints. . . Prevailing Wage Complaint form (F700-146-000) for prevailing wage violations. Protected Leave Complaint form (F700-144-000) for family leave, family care, leave for victims of domestic violence, sexual assault or stalking, spouse military leave, leave for voluntary firefighters on the scene. See the L&I Workplace Rights website for filing the various workplace rights complaints at www.Lni.wa.gov/WorkplaceRights. See the section titled “Complaints/Discrimination”. We do not accept wage complaints against. . . A business in which you are a part owner • (including family-owned). A business that owes money to a company you • own. Employers who have filed for bankruptcy. You • may file a “Proof of Claim” with the US Bankruptcy Court. Or when it’s about. . . Unpaid vacation, holiday pay, severance pay, or • reimbursement for expenses including fuel. If you are claiming wages for hours worked out• of-state for a non-Washington employer. Bank fees you paid because your employer’s • check bounced. A case you have already filed in court. • How to file your wage complaint: Complete and sign the attached form, use a sheet of paper if you need more space to explain your • complaint. Attach any information or records, such as time sheets or cards, calendars, or any personal records you • have that show the days and hours you worked and what tasks you did. This is very important to help us understand your complaint. Mail or bring the form and records to the L&I office in the county where the business is located. See back • of page. IMPORTANT: If you are moving, have a new telephone number, or are hiring an attorney, let us know right away. Call the local office where you filed your complaint or 1-866-219-7321. If we can’t contact you, this may delay the investigation or prevent us from being able to help you. If we can accept your complaint, we will: Assign an Industrial Relations Agent to investigate your complaint. In most cases, L&I must tell your • employer that you filed a complaint and send a copy of your complaint to the employer. Make a decision on your complaint within 60 days OR if we have good cause, notify you that we require • more time. IMPORTANT: If we cannot take your complaint, you have the right to either contact a private attorney OR file a suit in Small Claims Court for up to $5000. www.courts.wa.gov/newsinfo/resources/broc-hure_scc/smallclaims.doc F700-148-000 Worker Rights Complaint Form 01-2018 Where to file your complaint In person: OR By mail: Bring your completed form to the L&I office Mail the original of your completed form to the located in the same county where your L&I office located in the same county where your employer’s business is: employer’s business is. Write on the envelope: “Industrial Relations Agent, Dept. of Labor & Industries,” then the address of the office you selected. L&I Offices County where you worked Island San Juan Skagit Whatcom Snohomish King Pierce Clallam Jefferson Kitsap Grays Harbor Lewis Mason Thurston Pacific* Clark Klickitat Skamania Cowlitz Pacific* Wahkiakum Adams* Grant* (south of I-90) Kittitas Yakima Benton Columbia Franklin Walla Walla Chelan Douglas Grant (north of I-90) Okanogan Adams* (SE) Asotin Ferry Garfield Lincoln Pend Oreille Spokane Stevens Whitman Use this L&I office(s) Mount Vernon Bellingham Everett Bellevue Tukwila Tacoma Silverdale Sequim Address 525 East College Way Suite H Mount Vernon WA 98273-5500 1720 Ellis Street Suite 200 Bellingham WA 98225-4647 729 100th Street SE Everett WA 98208-3727 616 120th Avenue NE Suite C-201 Bellevue WA 98005-3037 12806 Gateway Drive S Tukwila WA 98168-3346 950 Broadway Suite 200 Tacoma WA 98402-4453 10049 Kitsap Mall Blvd Suite 100 Silverdale WA 98383 542 W Washington Street Sequim WA 98392 Phone Number 360-416-3000 360-647-7300 425-290-1300 425-990-1400 206-835-1000 253-596-3945 360-308-2800 360-417-2700 PO Box 44810 Olympia WA 98504-4810 7273 Linderson Way SW Tumwater WA 98501 360-902-5799 Aberdeen 415 Wishkah Street Suite 1-C Aberdeen WA 98520-0013 360-533-8200 Vancouver 312 SE Stonemill Drive Suite 120 Vancouver WA 98684-6982 360-896-2300 711 Vine Street Kelso WA 98626-2650 360-575-6900 15 West Yakima Avenue Suite 100 Yakima WA 98902-3480 509-454-3700 4310 West 24th Avenue Kennewick WA 99338-1992 509-735-0100 Olympia Kelso Yakima Kennewick East Wenatchee Moses Lake 519 Grant Road East Wenatchee WA 98802-5459 3001 West Broadway Avenue Moses Lake WA 98837-2907 509-886-6500 509-764-6900 Spokane 901 North Monroe Street Suite 100 Spokane WA 99201-2149 509-324-2600 Pullman PO Box 847 Pullman WA 99163-0847 1250 Bishop Blvd SE Suite G Pullman WA 99163 509-334-5296 F700-148-000 Worker Rights Complaint Form 01-2018 Worker Rights Complaint Form WA Unified Business Identifier (UBI): Employment Standards Program 360-902-5316 or 1-866-219-7321 A: Worker Information English Cambodian Language Preference (check one) Vietnamese Laotian Name (Last, First, MI) Mr. Mrs. Ms. Home Address City CATS #: Spanish Other: Russian Korean Chinese Simplified Social Security Number (optional) Complaint is for this period of time State Zip Code Email Address From: NAICS #: Date you began work with this employer Chinese Traditional Home Phone Number Cell Phone Number Your Pay Rate To: $ Are you still employed with company Yes If not still with this employer, last date employed No Reason for leaving job Fired Quit Laid Off Don’t know What kind of work did you do? B: Employer Information Name of Company Name of Company Owner, Manager, or Supervisor Company Mailing Address Company Phone Number Company Cell Phone Number Company Fax Number Company Email Address, if known City State Zip Code Address where you worked if not at the above address City State Type of Company (for example: construction, restaurant, janitorial) Zip Code Has the company filed for bankruptcy? Yes No Don’t know Is the company still in business? Yes No Don’t know C: Wage Complaint Information (Skip to Section D if your complaint is not about wages.) Important: If you or your attorney have already filed a complaint about these wages in court, we cannot accept your claim. What type of complaint are you filing? You may check more than one box below. Final wages not paid Overtime not paid Minimum wage not Willful failure to pay paid agreed wages Money taken out of Unpaid tips, my paycheck (not gratuities, service taxes) without my charges permission* Paid with NSF check Paid sick leave (bounced check) (also see Section E) Hours worked not paid * If you had a written agreement with your employer to deduct wages from your paycheck that wasn’t followed correctly, we will need a copy. Tell us in detail why you are filing this complaint. You may attach additional sheets if you need more room. If you have copies of any records that will help us understand your complaint, please attach them to this form. What wages do you believe are owed to you? Rate of pay per Hour Day Week Month Other rate of pay per: Piece rate Commission Sq. Ft. Flat rate Other (specify) $ $ __________ Wages owed: For how many hours? Partial payment received? What pay is owed to you before taxes? From: To: Reason employer gave for not paying you: F700-148-000 Worker Rights Complaint Form 01-2018 $ $ C: Wage Complaint Information (Continued) Check the box(es) below to show what records you are attaching Have you ever asked your employer for When was the scheduled payday for the to support your claim: your wages? Yes No wages you are claiming? If “Yes”, on what dates did you ask? Written wage agreement Payroll check stubs Shift schedules Copies of bad checks Personal time records Employee handbook How often are you paid? Monthly Twice monthly Every other week Weekly Daily Time card or copy Sick leave records Attendance rosters Other: Do you have a written employment Do you belong to a union? agreement? Yes No Yes No If “Yes”, what is your Log books If “Yes”, attach a copy. union’s name? Note: We also will be asking your employer for records. Were you paid straight time for Are overtime hours recorded? Did you receive pay stubs? Do you have pay stubs? overtime hours? Yes No Yes No Yes No Yes No If “Yes”, attach copies. Do you have an attorney who has filed an action Do you owe your employer any money? Do you have any property belonging to the in court to collect these wages? Yes No Yes No If “Yes”, amount owed: $______ business? Yes No If “Yes”, we cannot accept your complaint. Why: __________________________________ If “Yes”, list: Written agreement? Yes No Were you under 18 when employed? If “Yes”, attach a copy. Yes No If under 18 when you started work for this Were other worker affected? Yes No employer, date of birth: If so, how many? D: Non-Wage Complaint Information What type of non-wage complaint are you filing? Child labor laws were violated. (For example: employer hired underaged workers or did not follow working-hours rule for teen workers.) Tell us in detail why are filing this complaint. You may attach additional sheets if you need more room. Employer did not provide required time for meal periods Employer did not provide required time for rest periods. Employer did not pay for work uniform. RN or LPN nurse overtime rules were not followed. Employer retaliated against me. If you have copies of any records that will help us understand your complaint, please attach them to this form. Other: E: Alleged Type of Paid Sick Leave Violation Not allowing me to use sick leave. When did you ask for leave? Not compensating me for paid sick leave used. How much leave did you have in the bank? Not allowing me to carry over the unused paid sick leave. Not providing me regular notification of the paid sick leave balance. Other: F. If We Cannot Reach You. . . We need contact information for someone who will always know how to reach you. (Please don’t write your own address or phone number.) Your Contact’s Name Address City State Home Phone Number Cell Phone Number Zip Code Work Phone Number REQUIRED WORKER’S SIGNATURE To the best of my knowledge, the information I have entered on this form is true and accurate. Signature Date For more information about your workplace rights and responsibilities in Washington, to go: www.Lni.wa.gov/WorkplaceRights F700-148-000 Worker Rights Complaint Form 01-2018 RESET
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